Provider Demographics
NPI:1952342636
Name:HALL, BROOKE T (MD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:T
Last Name:HALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:BROOKE
Other - Last Name:TATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1420
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-0400
Mailing Address - Country:US
Mailing Address - Phone:541-706-2949
Mailing Address - Fax:541-706-2991
Practice Address - Street 1:2200 NE NEFF RD STE 302
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4279
Practice Address - Country:US
Practice Address - Phone:541-706-2949
Practice Address - Fax:541-706-2991
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-30259207R00000X
ORMD26770207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274758Medicaid
OR11308526OtherCAQH ID
OR11308526OtherCAQH ID